Drugs and Alcohol in the Workplace: A Problem of Impairment

Dr. Brendan AdamsMedical Occupational Services Team

October 6 , 2003Edmonton

What impact does impairment have on work?

Talk overview Common points of confusion:

Speaker Bias Lawyer/Human Rights Rep. Union/Employer Physician/Psychologist/Counselor Drug testing company Law enforcement

Effects of use in general population v. Alcohol/Drug Addicts

Why impairment is a problem:

Drug use, especially alcohol, is common. Impairment secondary to drug use often is

unrecognized by everyone, including the employee.

Drug use is part of our culture, and we have many “blind spots” – (mythology)

Impairment can, and too often does, have lethal consequences.

These losses, both financial and medical, are entirely preventable.

The obligatory statistics!

Worker absenteeism attributed to substance abuse costs Alberta economy approx. $720 million/year (1996).

More than 12,000 Alberta workers yearly know of a workplace injury(ies) that they believe were related to drug or alcohol use.

Direct losses in the Canadian workplace in 1992 were $4.2 billion.

In Alberta, 1995, 20.4% of all drivers in fatal crashes had been drinking.

Behind the statistics - Why you should care, because:

You are the one who gets killed or mutilated. Accidents affect a whole lot more than just your

job. You have a family or loved ones who care

about you, and depend on you. If you are young, you may be making choices

which will affect the rest of your life. What do you care about? You will lose it. Addiction/abuse is a spiritual illness. First the drinker takes a

drink…

Psychoactive substances

Why do we use them? Concept of neurotransmitters Concept of brain anatomy

Pleasure centers “Dopamine” disease Brain signals:

“Gotta have it” “Got it”

Drugs and Behaviours are similar at neuron level eg. Food, sex, gambling, risk-taking

Alcohol

Alcohol

Basic facts: Sedative/hypnotic Rapidly absorbed, slowed by food, water soluble Eliminated by zero order kinetics, one ounce per 3

hours (slower in women) Converted to acetaldehyde then to acetate One drink in North America = 12 grams EtOH Amount of pure ethanol calculated by %abv x .78

= gm EtOH/100 ml Advise maximum 2 standard drinks/day for men, 1

for women = low risk drinking

The basic problem of street drugs is not knowing what you’re putting in your body….not like alcohol, right?

Wine 1 standard drink (12 gm) = 130 ml (4.5 oz) of

12% wine = 110 Cal. 118 ml of 13%; 109 ml of 14%; How many standard drinks in a bottle? In a litre? Does champagne have more or less % EtOH? What percentage of alcohol in fortified wines?

(eg. Sherry, Dubonnet?) How much does a wine glass hold? Let’s find out!

Wine

One 750 ml bottle of wine contains 76 gm EtOH (13%) or 82 gm (14%), 6.3 or 6.8 standard drinks

A litre of wine contains 8.4 or 9.1 drinks Sparkling wines are typically 10-11% abv Wine glasses typically range from 4-12 oz (114-

342 ml) i.e. 1-3 standard drinks Sherry is 20% abv, Dubonnet = 16%; 1

standard drink is 76 ml (2 shot glasses) and 100 ml respectively

Ok…I don’t drink wine, but beer, I know.

Beer What % abv is beer? Strong beer? Lite beer? How many drinks is one bottle of beer? What if you drink supercans? How much beer in a pint? How much beer in a pitcher? What’s a “depth charge”?

Beer Standard beer is 5% abv, 355 ml bottles

which is 13.8 gm/bottle; 1.2 standard drinks. 5 bottles = 6 drinks Strong beer = (6-11%) 8.5% abv; 23.5 gm/bottle;

2 standard drinks Lite beer = 4% = 11 gm/bottle = .9 standard drinks Supercans = 473 ml; 1 supercan of Wildcat = 22.3

gm, approx 2 standard drinks Also available in 650 and 950 ml cans 1 pint = 2 cups = 455ml = 17 gm EtOH = 1.5

drinks; 2 pints = 3 standard drinks Pitcher = approx 1.5 litre = 58 gm = 5 drinks Depth Charge is 1.5 oz Vodka added to beer; 17

gm + 13.4 gm = 30 gm = 2.5 drinks

Confused? Don’t worry, spirits are much more complicated! What does ‘proof’ mean? What % abv is typical for spirits? How about

single malt scotch? How many drinks in 750 ml (26 oz) bottle, how

about 1.14l (40 oz)? How about liqueurs? Bailey’s vs Grand

Marnier? How about Alcopops? Where do they fit in?

Mike’s Hard Lemonade, Cider? How much is in that glass? How many standard

drinks is that? Does the amount of mix matter? How about ice? Let’s find out!

Spirits

Proof is 2x abv. Most spirits are 40% abv One standard drink is 38 ml, 1.4 oz Shot glass holds approx 50 ml, 1.3 drinks 750 ml bottle holds 234 gm, 19.5 drinks; 1.14 l

bottle holds 355 gm, 30 drinks Liqueurs range from 16% (Bailey’s) to 40%

(most) Studies show most people err by 2.5 to 3 times

in optical volume measurements Alcopops – 7% abv. Eg Mike’s = 18 gm/bottle =

1.5 standard drinks. Not the same as beer!

Alcohol

BAC – Blood Alcohol Concentrations. Measured in grams/100 ml blood.

.01 – marked increase in sleepiness. Impairs sleep. .02 – decreased ability to understand commands, esp.

radio. .05 – too impaired to operate a vehicle. 24 hour

suspension. Poor speed/distance perception. Poor problem solving skills.

.08 – “legally” impaired. .1-.19 – neurologic impairment, reaction time, ataxia.. .2-.3 – severe impairment .4 – hypothermia, stage 1 anaesthesia, aspiration .5-.8 – onset of coma, death

Alcohol

Metabolism decreases BAC by .015 per hour

A typical “night out” sees a BAC of .1 to .2 (10 -20 standard drinks)

Return to BAC of 0 will take more than 10 hours after last drink.

Impairment will last 20 – 30 hours See next slide for a “typical day”

Alcohol Facts 1 a.m. Drives home drunk BAC.165 2 a.m. Worker goes to bed .15 3 a.m. Sleeping .135 4 a.m. Bathroom .120 5 a.m. Restless .105 7 a.m. Alarm goes off .075 8 a.m. Drives to work impaired .060 8:30 a.m. Begins work impaired .055 Noon 0.0 Afternoon – hung over impairment continues

Impairment

Hung over state: Dehydration Metabolic Acidosis Hypoglycemia Disequilibrium Sleep debt Cognitive Impairment

So, if I carefully measure my drinks, I should know what my BAC is right? Um… not exactly. The Globe and Mail’s “Gord Campbell

experiment”

Failing to plan is planning to fail! The Teen Party Plan 55% of people under age 19 drink alcohol What is your party plan?

Decide whether you are going to drink. (It’s okay not to).

Decide what, when, where and how much. Plan how to stop, what to say etc. Pour your own! Plan on what to do if you/your friend makes a

mistake. Surrender car keys “Safe Ride” contract – “Code Red” Have you ever called a cab? What do you do with someone who is “passed

out”? Think about other alcohol influenced risky

behaviours (sex, drugs, water, machines)

Marijuana

Marijuana

Marijuana - devices

Marijuana

THC – delta 9 tetrahydrocannabinol MJ in 60’s typically 3-5%, now typically 10%,

can be 40% (hash oil, BC bud) Fat soluble (vs. EtOH) Long ½ life Binds to brain receptors, esp cerebellum

(driving) and hippocampus (learning); cumulative drug load

Extreme tolerance develops quickly Effects: next slide

Physical Psychological

Effects of Marijuana Use Physical:

Some estimates 20x carcinogenicity of cigarettes; (and additive to) – 60-70% more carcinogenic hydrocarbons

CAD, cardioacceleration, MI risk 4x in first hour

Anti-androgen, anti estrogenTHC crosses placental barrier, milk

Effects of Marijuana Use Psychological

Perceptual distortion, esp time/distance, peripheral vision, colour, attention.

Learning impaired – lasts 4 weeks. Addiction liability – similar to opiate w/d, less than coc. Classic W/D syndrome, esp. aggression, peaks @ 1

wk. U of Vermont study 6.3/9 criteria DSM IV

“Reefer Madness” – the ultimate irony

The marijuana – schizophrenia link Swedish study – 50,000 men followed for 27 years 50 x by age 18 increased schizophrenia by 30% 13% of all cases could be prevented by eliminating

marijuana British study – 1/10 smokers dx schiz by age 26

The depression link 6 year study of 2000 adolescent girls in NZ Daily users 5x likely to become depressed

Gateway drug – myth or fact?

Marijuana Myths It’s my own !*&# business what I do in my own

time… Impairment can be chronic

It’s a blue collar/cultural problem It’s less impairing than booze…

Wrong It’s safer than booze…

Wrong Doctors have found many medical uses for

marijuana… It’s a “soft” drug…. It’s not addictive…

Cocaine

Cocaine (crack, snow, blow, C, flake) “God” drug

One of the oldest known drugs Extracted from leaf of coca bush HCl salt or “freebase” (smokable – crackles)

Produces rush lasting 5-15 minutes, euphoria for 2-4 hours

Talkative/overconfident/irritable/energized Often use another drug to counter side

effects of jitteriness, irritability, depression One dose alters brain response (acute

tolerance) (next slide)

Cocaine

Cocaine Faster route – more intense effects

Initial impairment through euphoria/ poor judgment – to paranoia – to acute psychosis

Secondary impairment through “crash” and craving

Tertiary impairment through brain chemistry alteration and rapid development of addiction

Massive cardiac and respiratory side effects esp malignant arrythmia (risk 24x normal in first hour after use)

Seizures, (sensitization), sudden death

Cocaine and Alcohol

“One plus one equals three!” New compound – cocaethylene

Manufactured in the liver Increases impulsivity Profoundly impairs judgment and memory Increased risk of sudden death

The most common two drug combination that results in death

Memory impairment vastly potentiates relapse

“Crystal Meth”(Methamphetamine) (meth, crystal, ice, jib, crank, speed)

“Crystal Meth”(Methamphetamine) (meth, crystal, ice, jib, crank, speed)

Man made analog of amphetamine. Smokable. Made in basement labs.

Triggers massive release of dopamine – intense “rush”

Neurotoxic in animal models – destroys dopamine and serotonin neurons (next slides). Long term damage

Predisposition to neurodegenerative diseases later in life?

“Crystal Meth”

“Crystal Meth”

Crystal Meth Impairment

Impairs tests of perceptual speed, manipulation of information

Impairment of coordination Violent behaviour more common with

this drug than others “tweaking”

Ecstacy

Ecstasy

MDMA – “E” Methylenedioxyamphetamine Hallucinogen, (euphoria, depression) Effects last 4-6 hours, after effects last weeks

to months Works on serotonin system (mood) May damage neurons permanently after 1

use Addictive potential like very weak cocaine Malignant hyperthermia, chronic paranoid

psychosis, cardiac arrest, coagulopathy

A Drug is a Drug is a Drug!

Prescription Drug Abuse 3 Major Categories

Opioids (Tylenol #3) Depressants (Valium, Imovane) Stimulants (Dexedrine, Ritalin)

Drug Myths I am stronger than the drug – I can control what

others cannot. I’ve quit before, I can again. Drugs make me more creative/social etc. Life is better stoned. Drugs do no permanent harm. What I do in my own time is my own business –

the company doesn’t own my soul! Don’t tell me what to do! Doctors/counselors/authorities are liars. *** is way safer than alcohol. I know a guy who’s been doing this for years

and he’s fine…

Summary of First Section

Alcohol is alcohol. Alcohol is a drug A drug is a drug is a drug There are no “safe” or “soft” drugs. Just

different. Impairment is quite different than intoxication All psychoactive drugs impair an person’s ability

to work/learn safely – sometimes for several weeks after ingestion. Sometimes permanently.

Almost everyone is unaware of the extent of their impairment

There are no easy answers to drug use in society

Summary – some suggestions from what we’ve learned so far:

Know more. Talk more. Use/buy smart. Decrease your use. Shandys, spritzers It’s okay not to use. Support those who don’t. Some people should never use psychoactive

drugs of any kind. Avoid early introduction of alcohol in a child’s

life “Just say no” is not an effective strategy for kids Consequences for use are essential. Avoid

normalizing abnormal. Do you, or a love one, have a problem? Next

section…

Section 2 – Alcohol and drug addiction Addiction is a very distinct entity from use or

abuse It is a disease with well recognized symptoms Hallmark symptoms are loss of control and

tolerance Addiction involves changes in brain

chemistry/structure, and is irreversible 2/3 of alcohol addiction is genetic Addiction is a family disease There are only 4 outcomes to drug/alcohol

addiction There is only one treatment - abstinence

Addiction in the Workplace

This is a whole separate topic Consider:

Not all users are abusers/addicts! Detection/ Performance Management Intervention, progressive model Bipartite approach essential Policy/procedure addressing each step Re-integration and aftercare the most

critical stage Relapse prevention and safety

Alcohol addiction Affects 6% general population, (10-12% of oil

patch as industry) Reasons for increase is industry co-

dependency*, lack of direct supervision, irregular hours, ability to shift employers

Typically takes 5-10 years to develop (see following slides). Follows typical course

The Alcoholic is impaired from chronic alcohol effects in addition to acute effects already discussed

Chronic effects: hepatitis, hypertension, “wet brain”, blackout, DT/w/d seizures, chaotic life syndrome

Enabling/co-dependency

“We enable another person when we protect them from experiencing the consequences of their behaviour”

Accepting excuses Making excuses for another’s behaviour Covering up for those experiencing problems Giving people “breaks” Ignoring or avoiding the problem Treating the problem as a joke

Enabling is usually well intentioned Reasons:

To avoid conflict Because we feel helpless To avoid embarrassment or stigma Because we feel the problem is somehow a

reflection of our own competence Because we might have to face our own

problem

Enabling results in the person’s death After spouses and co-workers, Doctors

are often prime enablers!

Drug Testing

`No, no!' said the Queen. `Sentence first--verdict afterwards.'

Alice in Wonderland by Lewis Carroll

Drug Testing

Really, a whole separate lecture. Briefly: What are you trying to accomplish?

Model of change

Consider examples of Traffic radar Prohibition

Must be part of an effective, enlightened policy/process

Must be used in concert with performance management/ other HR tools

Information Sources

National Institute on Drug Abuse www.drugabuse.gov Substance abuse network of Ontario

http://sano.camh.net/ National Institute on Alcohol Abuse and Alcoholism

www.niaaa.nih.gov The National Council on Alcoholism and Drug

Dependence www.ncadd.org AADAC www.aadac.com/ AA/NA/CA www.aa.org/ etc. Recovery www.recovery.org/ Literature www.hazelden.org/ Local expert: Dr. Dan Ryan, 2835 Millwoods Road NW,

450-4550